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RESEARCH ARTICLE| Volume 54, ISSUE 5, SUPPLEMENT 2, S124-S129, May 2018

Increase in Physical Activity Sustained 1 Year After Playground Intervention

      Introduction

      Regular physical activity is a vital component of child health, and schools play an important role in the promotion of physical activity among children. This paper describes the implementation and evaluation of a playground redesign involving structural and loose play equipment to increase students’ physical activity at an intermediate school in Leadville, Colorado.

      Methods

      Direct observations were conducted during recess before the redesign in May 2014, then again at 6 months and 1 year after the redesign. During each observation, observers scanned the playground and counted how many students were sedentary, engaged in moderate activity, or engaged in vigorous activity. System for Observing Play and Leisure Activity in Youth, a validated instrument for observing physical activity in free play settings, was used to collect observation data.

      Results

      Six months from baseline, the percentage of children engaging in moderate to vigorous physical activity during recess increased by 23.3%, and the percentage engaged in vigorous physical activity increased by 26.2%. These increases were sustained at 1 year from baseline, with an increase of 17.2% for moderate to vigorous physical activity and 33.1% for vigorous physical activity. Chi-square tests of independence showed that changes in the proportion of students engaging in moderate to vigorous physical activity and vigorous physical activity were statistically significant (p<0.01).

      Conclusions

      This evaluation demonstrated that environmental interventions involving the provision of structural and loose play equipment can be implemented in an intermediate school setting, and can create a sustainable increase in physical activity among students during recess. This example also demonstrates that schools and community organizations can evaluate the impact of these interventions using relatively simple, low-cost observational methods.

      Supplement information

      This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

      Introduction

      Regular physical activity is a vital component of child health, as it is associated with numerous health benefits and helps to prevent chronic disease later in life.
      • Janssen I.
      • LeBlanc A.G.
      Systematic review of the health benefits of physical activity and fitness in school-aged children and youth.
      Children aged 6–17 years should get at least 60 minutes of moderate to vigorous physical activity (MVPA) daily

      U.S. DHHS. Physical Activity Guidelines Advisory Committee Report. Washington, DC: DHHS. http://health.gov/paguidelines/report. Published June 2008. Accessed June 30, 2016.

      ; however, it is estimated that only 21% of U.S. youth meet this recommendation.

      National Physical Activity Plan. The 2016 United States Report Card on Physical Activity for Children and Youth. Columbia, SC: NPAP. www.physicalactivityplan.org/reportcard/2016FINAL_USReportCard.pdf. Published 2016. Accessed October 19, 2017.

      Schools play an important role in the promotion of youth physical activity, being both a place where youth spend much of their time and an apt setting for teaching them how to maintain an active lifestyle.

      CDC. Youth Physical Activity: The Role of Schools. Atlanta, GA: CDC. www.cdc.gov/healthyschools/physicalactivity/toolkit/factsheet_pa_guidelines_schools.pdf. Published August 2009. Accessed June 30, 2016.

      Strategies that alter the school environment to promote physical activity are included in the Centers for Disease Control and Prevention School Health Guidelines as an essential component of school-based health promotion,
      CDC
      School health guidelines to promote healthy eating and physical activity.
      and providing optimal conditions for physical activity during recess has been identified as especially important.

      Beighle A. Increasing Physical Activity Through Recess: A Research Brief. Princeton, NJ: Active Living Research. https://activelivingresearch.org/increasing-physical-activity-through-recess. Published January 2012. Accessed October 21, 2017.

      Though environmental strategies often cost more to implement initially, particularly strategies that involve permanent (i.e., structural) changes, they may create a more sustained impact than programmatic or educational interventions that rely on continued funding.
      Four systematic reviews have been conducted since 2013 examining the evidence for physical activity promotion in school playgrounds, identifying a total of 12 interventions that included only environmental strategies (i.e., excluded educational or programmatic components). These reviews have concluded that there is moderate evidence suggesting that environmental playground interventions increase physical activity levels during recess, particularly interventions that provide play equipment.
      • Ickes M.J.
      • Erwin H.
      • Beighle A.
      Systematic review of recess interventions to increase physical activity.
      • Parrish A.M.
      • Okely A.D.
      • Stanley R.M.
      • Ridgers N.D.
      The effect of school recess interventions on physical activity.
      • Broekhuizen K.
      • Scholten A.M.
      • de Vries S.I.
      The value of (pre) school playgrounds for children’s physical activity level: a systematic review.
      • Escalante Y.
      • García-Hermoso A.
      • Backx K.
      • Saavedra J.M.
      Playground designs to increase physical activity levels during school recess a systematic review.
      Although the majority of studies in these reviews either had no follow-up or measured outcomes less than 4 months post-intervention, more recent studies of environmental playground interventions have examined outcomes over a longer follow-up period (ranging from 8 to 12 months).
      • Hyndman B.P.
      • Benson A.C.
      • Ullah S.
      • Telford A.
      Evaluating the effects of the Lunchtime Enjoyment Activity and Play (LEAP) school playground intervention on children’s quality of life, enjoyment and participation in physical activity.
      • Janssen M.
      • Twisk J.W.R.
      • Toussaint H.M.
      • et al.
      Effectiveness of the PLAYgrounds programme on PA levels during recess in 6-year-old to 12-year-old children.
      • Van Kann D.H.
      • de Vries S.
      • Schipperijn J.
      • de Vries N.K.
      • Jansen M.W.
      • Kremers S.P.
      A multicomponent schoolyard intervention targeting children’s recess physical activity and sedentary behavior: effects after one year.
      Most studies examining long-term outcomes have found sustained increases in MVPA,
      • Hyndman B.P.
      • Benson A.C.
      • Ullah S.
      • Telford A.
      Evaluating the effects of the Lunchtime Enjoyment Activity and Play (LEAP) school playground intervention on children’s quality of life, enjoyment and participation in physical activity.
      • Janssen M.
      • Twisk J.W.R.
      • Toussaint H.M.
      • et al.
      Effectiveness of the PLAYgrounds programme on PA levels during recess in 6-year-old to 12-year-old children.
      • Ridgers N.D.
      • Fairclough S.J.
      • Stratton G.
      Twelve-month effects of a playground intervention on children’s morning and lunchtime recess physical activity levels.
      though one study found increases for light physical activity but not MVPA.
      • Van Kann D.H.
      • de Vries S.
      • Schipperijn J.
      • de Vries N.K.
      • Jansen M.W.
      • Kremers S.P.
      A multicomponent schoolyard intervention targeting children’s recess physical activity and sedentary behavior: effects after one year.
      This paper describes the implementation and evaluation of a playground redesign involving structural and loose play equipment to increase students’ physical activity at recess. The evaluation measured changes in physical activity over a 12-month period, aiming to assess longer-term sustainability. The observational methods described provide an example of how schools can measure effectiveness of playground changes in an efficient and low-cost manner.

      Methods

      The Kaiser Permanente Colorado’s Community Health Initiative was implemented through LiveWell Colorado with an emphasis on increasing access to healthy eating and active living through policy, built environment, and lifestyle changes.
      • Cheadle A.
      • Schwartz P.
      • Rauzon S.
      • Beery W.
      • Gee S.
      • Solomon L.
      The Kaiser Permanente community health initiative: overview and evaluation design.
      LiveWell Colorado’s model has funded 32 communities for 7–9 years, with the first year of limited funding focused on mobilization and planning, middle years with highest funding directed toward intervention implementation, and reduced funding in final years focused on sustainability of the initiative. This study was reviewed by the Kaiser Permanente Washington Health Research Institute (formerly Group Health Research Institute). The Group Health Research Institute IRB originally determined that this evaluation activity was not human subjects research. Observers gained additional approval from the school district and school principal prior to conducting observations at all three time points. The IRB that exempted the study and the school district and principal did not require consent from participants, as no individual-level data were collected.

      Study Sample

      One LiveWell Colorado community, Leadville, implemented a playground redesign at an intermediate school serving students in fifth to sixth grades. The original playground included a swing set with two functional swings, a rusty metal climbing structure, an ungraded steep hillside, a dirt/loose gravel space that was unsafe for running, and an unusable basketball court. No loose equipment was present at baseline. The redesign involved the replacement of structural equipment with six swings, a mesh climbing structure, slides, and a spinning carousel. A new outdoor basketball court, walkways, boulder retaining walls, and grass-covered open play area were also constructed. Additional loose equipment was provided during post-observations, including balls, hula hoops, and cones for creating a course. The total cost of the redesign was $555,138.00 (including in-kind donations), raised from various sources including philanthropic foundations, county and city government, and the school district.

      Measures

      Direct observation data were collected using System for Observing Play and Leisure Activity in Youth (SOPLAY), an instrument designed to assess students’ physical activity levels and environmental contexts during play and leisure time in a specified area.

      McKenzie TL. SOPLAY: description and procedures manual. http://activelivingresearch.org/sites/default/files/SOPLAY_Protocols.pdf. Published 2006. Accessed July 13, 2016.

      The instrument used in the present study was slightly modified in that it did not ask observers to differentiate between girls and boys. One study using heart rate monitoring established support for the initial construct validity of SOPLAY,
      • Rowe P.J.
      • Schuldheisz J.M.
      • Van der Mars H.
      Measuring physical activity in physical education: validation of the SOFIT direct observation instrument for use with first to eighth grade students.
      and a later study found the tool to be a valid indicator of MVPA for behavior coded as vigorous by observers.
      • Saint-Maurice P.F.
      • Welk G.
      • Ihmels M.A.
      • Krapfl J.R.
      Validation of the SOPLAY direct observation tool with an accelerometry-based physical activity monitor.
      Observers received an in-person training in SOPLAY by a team member from the Institute for Health Research who had expertise and experience using the modified version of SOPLAY in other school settings. Training included how to identify scan areas that were predefined on a playground map, directionality to scan, and how to count youth entering/leaving scan areas and changing activities (depending on whether it was to the left or right of the current scan location). Observers then practiced scans at the school together in pairs and had an inter-rater reliability of >90%. To minimize potential observer drift over time, refresher trainings were conducted and inter-rater reliability was ensured to be still >90% before each observation time point.
      Recess was a mandatory, 25-minute period of the daily school schedule at all observation periods. Fifth- and sixth-graders had separate recess periods, with similar numbers of students (60–70) using the playground during a given recess period at all time points. Observations were conducted during the two recess periods (one fifth grade, one sixth grade) at three time points: May 2014 (before the redesign); November 2014 (6 months after redesign); and May 2015 (1 year after redesign). Two observers were present at each observation. Each observer conducted successive scans of different predefined areas of the playground, counting how many children in each area were sedentary, moderately active, or vigorously active. There were five scan areas at baseline, and six scan areas at follow-up (one was added because of the changes made in the redesign). Each scan area was observed twice (once by each observer) during each recess period, and the average of their responses was used for analysis. Final results were calculated by averaging counts of the two observers. To help ensure continuity, one observer was present at all three time points and observations were conducted at the same time of day for all time points. To minimize bias, the observers were not members of the analysis team.
      In-person observations were recorded on paper using a standardized tool. Students were recorded as being sedentary, moderately active, or vigorously active. Sedentary behavior was defined as sitting or standing. Moderate physical activity was defined as walking or slow-moving activities. Vigorous physical activity was defined as running, climbing, or fast-paced activities, such as basketball. Environmental factors were also recorded for each scan area, including accessibility, usability, presence of supervision, presence and type of organized activity, and availability of equipment. Additionally, observers recorded the time of day, length of the recess period, weather conditions, and the main activities that students were observed to be doing in each area.

      Statistical Analysis

      This study employed a pre–post evaluation design in which students’ physical activity levels were compared before and after the intervention. The percentage of observed students who were sedentary, moderately active, and vigorously active was calculated for each time point. Because the DHHS recommendations refer to MVPA,

      U.S. DHHS. Physical Activity Guidelines Advisory Committee Report. Washington, DC: DHHS. http://health.gov/paguidelines/report. Published June 2008. Accessed June 30, 2016.

      the primary outcome examined was percentage of students who engaged in either moderate or vigorous physical activity (VPA). However, because the most recent validation study of SOPLAY found that activity coded as vigorous may be the most valid indicator of MVPA, VPA alone was also examined. The change in percentage for each of these outcomes was examined from baseline to 6 months, then again from baseline to 1 year. Chi-square tests of independence were performed to determine whether changes were statistically significant. Primary analyses combined fifth- and sixth-grade students, which were then conducted separately to look for differences between grades. Analyses were conducted in SPSS, version 19.0.
      Additionally, the Center for Community Health and Evaluation’s population-dose approach was used to estimate the population-level dose and impact of the intervention.

      Center for Community Health and Evaluation. Healthy Dose: A Toolkit for Boosting the Impact of Community Health Strategies. Seattle, WA: CCHE. https://share.kaiserpermanente.org/wp-content/uploads/2015/08/DoseToolkitVersion1.0.pdf. Published 2015. Accessed September 7, 2016.

      Population dose is estimated by multiplying the estimated reach of a strategy (percentage of the target population exposed) by the strength (estimated percentage change in behavior times frequency times duration). In this case, reach was defined as percentage of students at the school exposed to the new playground. Strength was defined as percentage change in physical activity during the 25-minute recess, divided by an estimated 55 minutes per day baseline level of physical activity based on the Centers for Disease Control and Prevention estimates for this age group,
      • Troiano R.P.
      • Berrigan D.
      • Dodd K.W.
      • et al.
      Physical activity in the United States measured by accelerometer.
      multiplied by 5/7 or ~0.71 days a week, 36/52 or ~0.69 weeks a year that school is in session.

      Results

      The study population consisted of 148 students in fifth and sixth grade. One hundred forty-three students (96.6% of enrolled fifth- and sixth-graders) were observed at baseline; 121 (81.7%) at 6 months; and 129 (87.8%) at 1 year. Demographic data were not collected at the individual participant level. At the school level, 50.0% of students were male and 50.0% were female. The majority of students at the school were Hispanic/Latino (71.3%); 26.4% were white; 1.0% were American Indian/Alaska Native; 1.0% were two or more races; and 0.3% were black/African American. The majority (77.7%) of students at the school received free or reduced-price lunch. (Note that these statistics describe the makeup of the entire school, and not the participants in this study; these figures were provided by the school district.)
      Figure 1 shows the percentage of students who were observed to be sedentary, moderately active, or vigorously active during recess at each time point. Figure 2, Figure 3 show the same data separated for fifth and sixth grades.
      Figure 1
      Figure 1Changes in observed student physical activity during recess: Grades 5–6.
      *Statistically significant difference from baseline (p<0.05).
      Figure 2
      Figure 2Changes in observed student physical activity during recess: Grade 5 only.
      *Statistically significant difference from baseline (p<0.05).
      Figure 3
      Figure 3Changes in observed student physical activity during recess: Grade 6 only.
      *Statistically significant difference from baseline (p<0.05).
      From May 2014 to November 2014, the percentage of children engaging in MVPA during recess increased by 23.3%. This change was sustained at 1 year from baseline, with an increase of 17.2% from May 2014 to May 2015. The increase was greater for VPA alone. From May 2014 to November 2014, the percentage of children engaged in VPA during recess increased by 26.2%. This change was sustained at 1 year from baseline, with an increase of 33.1% from May 2014 to May 2015 (Figure 1). Across all three time points, fifth-graders were observed to be more active than sixth-graders. The increase in MVPA was roughly similar between grades; however, the increase in VPA was greater for fifth-graders (Figure 2, Figure 3).
      Chi-square tests of independence were performed to examine changes in MVPA and VPA over time. The change in the percentage of students engaged in MVPA from baseline to the 1-year follow-up was significant (p<0.05). The change in the percentage of students engaged in VPA from baseline to the 1-year follow-up was also significant (p<0.05; Figure 1).
      Because the combined groups were not completely independent between baseline and follow-up (fifth-graders at baseline were sixth-graders at both follow-ups), analyses were also conducted separately for fifth- and sixth-grade observations in which the baseline and follow-up groups were completely independent. There were no major differences in trends between fifth- and sixth-grade groups. Both groups showed a sustained increase in MVPA between baseline and the 1-year follow-up; however, this was statistically significant only for sixth-graders. Change in VPA from baseline to the 1-year follow-up was still significant for both grades (Figure 2, Figure 3).
      At all time points, all scan areas were observed to be accessible, usable, and supervised. No scan areas were observed to be organized at any time point (meaning having an organized activity guided by school staff). No scan areas had loose equipment at baseline, but scan areas with loose equipment at follow-up time points contained more students who were physically active as they were engaged in games (e.g., basketball, soccer).
      Using the population–dose approach,

      Center for Community Health and Evaluation. Healthy Dose: A Toolkit for Boosting the Impact of Community Health Strategies. Seattle, WA: CCHE. https://share.kaiserpermanente.org/wp-content/uploads/2015/08/DoseToolkitVersion1.0.pdf. Published 2015. Accessed September 7, 2016.

      the reach of this intervention was estimated to be 88.7% (the average percentage of the 147 enrolled fifth- and sixth-grade students counted on the playground at the three time points). Note that the intervention does not reach all enrolled students during every recess period, because of absences or students being engaged in other activities during recess (e.g., using the restroom, talking to a teacher). Strength was calculated as a 17.2% increase in students engaging in nonsedentary behavior after 1 year during the 25-minute recess; divided by 55 minutes (baseline average daily physical activity); multiplied by frequency of 5/7 days a week; and duration 36/52 weeks a year: (17.2% change) x (25/55 minutes) x (5/7 days/week) x (36/52 weeks a year)=strength of 3.9%. Population-level dose was estimated to be 88.7% (reach) x 3.9% (strength)=3.5% (p<0.05) sustained increase in annual physical activity for enrolled students as a result of this environmental change, or 1.9 more minutes per day over a baseline of 55 minutes.

      Discussion

      The results of this study were consistent with existing research showing positive evidence for environmental playground interventions.
      • Ickes M.J.
      • Erwin H.
      • Beighle A.
      Systematic review of recess interventions to increase physical activity.
      • Parrish A.M.
      • Okely A.D.
      • Stanley R.M.
      • Ridgers N.D.
      The effect of school recess interventions on physical activity.
      • Broekhuizen K.
      • Scholten A.M.
      • de Vries S.I.
      The value of (pre) school playgrounds for children’s physical activity level: a systematic review.
      • Escalante Y.
      • García-Hermoso A.
      • Backx K.
      • Saavedra J.M.
      Playground designs to increase physical activity levels during school recess a systematic review.
      • Hyndman B.P.
      • Benson A.C.
      • Ullah S.
      • Telford A.
      Evaluating the effects of the Lunchtime Enjoyment Activity and Play (LEAP) school playground intervention on children’s quality of life, enjoyment and participation in physical activity.
      • Janssen M.
      • Twisk J.W.R.
      • Toussaint H.M.
      • et al.
      Effectiveness of the PLAYgrounds programme on PA levels during recess in 6-year-old to 12-year-old children.
      • Van Kann D.H.
      • de Vries S.
      • Schipperijn J.
      • de Vries N.K.
      • Jansen M.W.
      • Kremers S.P.
      A multicomponent schoolyard intervention targeting children’s recess physical activity and sedentary behavior: effects after one year.
      • Ridgers N.D.
      • Fairclough S.J.
      • Stratton G.
      Twelve-month effects of a playground intervention on children’s morning and lunchtime recess physical activity levels.
      Further, the finding that significant effects were maintained after 12 months suggests that these changes are sustainable over time, consistent with most studies that have examined long-term outcomes.
      • Hyndman B.P.
      • Benson A.C.
      • Ullah S.
      • Telford A.
      Evaluating the effects of the Lunchtime Enjoyment Activity and Play (LEAP) school playground intervention on children’s quality of life, enjoyment and participation in physical activity.
      • Janssen M.
      • Twisk J.W.R.
      • Toussaint H.M.
      • et al.
      Effectiveness of the PLAYgrounds programme on PA levels during recess in 6-year-old to 12-year-old children.
      • Ridgers N.D.
      • Fairclough S.J.
      • Stratton G.
      Twelve-month effects of a playground intervention on children’s morning and lunchtime recess physical activity levels.
      Based on the success of this intervention, program coordinators are expanding it to another school in the same community.
      Fifth-graders were observed to be more active than sixth-graders at each time point, a finding that is consistent with national data showing that youth aged 12 years and older are typically less active than younger children.
      • Dentro K.N.
      • Beals K.
      • Crouter S.E.
      • et al.
      Results from the United States’ 2014 report card on physical activity for children and youth.
      Additionally, analyses stratified by grade suggested that the intervention was similarly effective for both grades in increasing MVPA, but may be somewhat more effective in increasing VPA for fifth-graders, a finding that is reflected in other intervention studies.
      • Ridgers N.D.
      • Stratton G.
      • Fairclough S.J.
      • Twisk J.W.
      Long-term effects of a playground markings and physical structures on children’s recess physical activity levels.
      During the post observations, the observers noted qualitative information providing insight into what specific features of the new playground may have contributed the most to increased physical activity among students. The grass-covered open play area and basketball court were observed to contribute the most to increased VPA when the spaces were used to play soccer, football, or basketball. The swings and slide were almost always in use, generally contributing to moderate activity. Observers noted that the spinning carousel was most often used as a place to sit and talk, contributing to sedentary behavior. These qualitative observations support the provision of open space and equipment to play competitive team games, as well as structural equipment that encourages movement including swings and slides. They suggest that equipment that inadvertently provides group sitting space, such as the carousel, be avoided. Future evaluations of similar interventions should consider collecting additional supplemental data from teachers, students, or administrators to better understand what specific components of a playground redesign contribute to increases in physical activity.

      Limitations

      There were several limitations to this study that should be noted. Although the pre–post design allows for some confidence that the intervention contributed to the observed changes in physical activity, the absence of a control group limits the ability to make this inference. Although SOPLAY has been validated against accelerometers and potential misclassification was accounted for by examining changes in VPA alone, using accelerometers would have provided a more direct and reliable measurement of the outcome. Also, the evaluation being conducted in only one school limits the generalizability of these findings in different school settings.
      This evaluation did not collect data on students’ genders, and thus cannot account for gender differences in physical activity increases. Additionally, the SOPLAY tool cannot account for how the social environment—including conflict and conflict resolution, collaboration and engagement, positive language, and reinforcement of playground norms—impacts students’ physical activity during recess.
      A few additional issues should also be addressed. Students observed during May 2014 were not the exact same group of students that were observed during November 2015 and May 2015, because one cohort of students moved into seventh grade and a new cohort of students entered fifth grade. From this study design and analysis, it can be concluded that the percentage of active students on the playground at a given time appeared to increase after the intervention; however, this study cannot conclude that activity increased for any particular individual student that was observed. This raises the possibility that outside factors contributed to the observed changes in physical activity. Given the generally consistent demographics of the school, the contribution of outside factors is likely minimal.
      The outdoor temperature was colder during May 2014 (about 40°F) than May 2015 (about 50°F). There is evidence indicating that warmer temperatures in this range are associated with increased physical activity among children,
      • Remmers T.
      • Thijs C.
      • Timperio A.
      • et al.
      Daily weather and children’s physical activity patterns.
      • Harrison F.
      • Goodman A.
      • van Sluijs E.M.F.
      • et al.
      Weather and children’s physical activity; how and why do relationships vary between countries?.
      therefore temperature may have been a confounder in this study. However, some authors have noted that the evidence regarding whether and in what direction temperature impacts physical activity among children is inconclusive,
      • Ridgers N.D.
      • Salmon J.
      • Parrish A.M.
      • Stanley R.M.
      • Okely A.D.
      Physical activity during school recess: a systematic review.
      and others have concluded that seasonality has a limited impact on children’s physical activity.
      • Fisher A.
      • Reilly J.J.
      • Montgomery C.
      • et al.
      Seasonality in physical activity and sedentary behavior in young children.
      Despite these limitations, this project demonstrated that an environmental playground redesign was feasible to implement in an intermediate school setting, and observational evaluation data suggest that there was a significant increase in physical activity sustained 1 year after implementation. The observational methods described here provide an example of how schools and community organizations can evaluate the impact of their playground interventions in a relatively simple and low-cost manner, which may be important in cases where resources for evaluation are limited.

      Conclusions

      This paper describes the implementation and evaluation of an environmental intervention involving structural and loose play equipment to increase students’ physical activity during recess. The percentage of children observed engaging in MVPA and VPA during recess significantly increased at 6 months from baseline, and these increases were sustained at 1 year from baseline. This evaluation demonstrated the feasibility of implementing environmental playground interventions in an intermediate school setting, and suggests that such interventions can create a sustainable increase in physical activity. This example also demonstrates that schools and community organizations can evaluate the impact of their intervention using relatively simple, low-cost observational methods.

      Acknowledgments

      The authors would like to acknowledge Kerri Quinlan, Director of Healthy Schools at Lake County School District, for assisting with data collection, and the LiveWell Leadville community coalition and town residents for their contributions to Healthy Eating and Active Living efforts in Leadville. Volunteers on the Lake County Intermediate School Play Yard Action Team and staff at the Lake County School District, Lake County Build a Generation, and Lake County Recreation Department worked over several years to raise funding for the playground, design the new playground, and ensure its completion.
      This project was funded through several sources, including significant cash or in-kind donations from the Department of Local Affairs, the Freeport McMoRan Foundation, the Gates Family Foundation, the Summit Foundation, Great Outdoors Colorado, the Lake County School District, the Leadville Trail 100 Legacy Foundation, Lifetime Fitness, Lake County, and the City of Leadville. The authors also acknowledge and thank Kaiser Permanente for financial support.
      Kelly Landau and Katie Baldassar contributed to evaluation planning and data collection. Madeline Frost, Lisa Harner, and Elena Kuo conducted the analyses. Madeline Frost, Elena Kuo, and Lisa Harner contributed to writing the manuscript. Kelly Landau and Katie Baldassar provided feedback on the manuscript.
      No financial disclosures were reported by the authors of this paper.

      Supplement Note

      This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives: Evaluations from 10 Years of Kaiser Permanente's Community Health Initiative to Promote Healthy Eating and Active Living, which is sponsored by Kaiser Permanente, Community Health.

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